In my public practice (which is clinical at an outpatient community behavioral health clinic and under LCSW supervision), I practice therapy, in my private practice I practice counseling (there are many differences). One of the primary differences is whether or not I am diagnosing, and the scope of what clients I will or will not see (among others).
I was discussing recently with a friend and colleague, former professor, mentor, and one of the people who got me started on my path to be a Solutions Focused Counselor/Therapist (that’s a lot of titles) what my notes look like as a Solutions Focused Brief Therapist in public practice in the United States where, especially when billing insurance, we must justify our work through documentation, to say nothing of our ethical requirements to document appropriately…so I figured I’d share the template and format I use.
I have come up with the following format for therapeutic interactions which, with the exception of the MSE, I write collaboratively with my patients. This takes no more than five minutes at the end of our session, and ensures I don’t ever get behind on paperwork/case noting.
I do not take any notes during a session in order to foster open and direct communication. There is nothing between myself and the patient (no pad, no pen). This requires a great amount of practice in active listening. I recommend a lot of role play to become comfortable with the technique.
Below is an example of a contrived session I made up about John Doe, it should bear no resemblance to anyone living or dead since I just came up with it on the fly, sans-coffee, while waiting for my flight:
Patient presented on time, dressed appropriately, appeared alert and well-oriented. There was no evidence of disruption in speech flow or content, memory, or perception. Current mood observed as euthymic with affect congruent to mood. Thoughts were organized and goal-directed. Judgment appeared good, and insight appeared moderate.
Patient presented with:
– Symptoms is depression;
– Symptoms is anxiety;
– Difficulties managing moods/emotions;
– Stressors Regarding Family;
– Stressors Regarding Work.
WBTW (What’s Better This Week): John Doe shared that this week he was able to get out of bed and go to classes twice. John shared that he was also able to wash half of the dishes in his sink.
Scaling (1-10/Zombies-to-Unicorns): 4.5; Goal (1-10): 5/John shared that he will be at a 5 when he is able to do all of the dishes and is able to go to all of his classes.
Discernment: John and this writer discussed barriers to doing his dishes and to attending classes, and how these barriers are negatively impacting his mental health symptoms**.
Exceptions: John shared that the problem of doing dishes and cleaning in general is not a problem when he comes right home after work. John shared that attending classes weren’t an issue when he got more sleep.
Experiment: John was able to brainstorm ways in which he can address his barriers to move to a 5 on the scale. John will try to do dishes twice this week right after work. John decided he will set a reminder on his phone to go off part way through his commute to remind him. John will set his bedtime back by an hour to get an extra hour of sleep.
Clinical/Psychoeducation: This writer provided psychoeducation on the importance of sleep hygiene and behavioral activation for reducing the sxs of depression.
Risk Assessment: John denied thoughts, plans, or intents or harming himself or others.
Follow Up: Follow up in two weeks. John to complete experiment as outlined above. John will call/come in if he requires additional support between now and his next appointment.
**While problem talk is discouraged, linking the patients concerns, and treatment to their mental health symptoms in discussion is necessary for ethical treatment under insurance. This is possible even in SFBT when we look at the “preferred future” (i.e. “I won’t be so anxious,” or “I won’t be as depressed,” etc.). We have to show how they are negatively impacting mental health symptoms because that is the structure of the medical/insurance setup in the United States.
In any event, I hope this is helpful to the wider SFBT community who is forced to balance SFBT work and insurance (without which, only the wealthy could afford our services), and I look forward to turning this into some kind of presentation at some point (SFBT & Insurance: An Uneasy Truce?).